Amref Health Africa welcomes the news that the WHO has given the green light for the roll-out of Mosquirix, a promising malaria vaccine. In a year that has seen the development of several viable COVID-19 vaccines, this represents another remarkable breakthrough for science. Alongside other tools, it will be a vital asset in the fight to end malaria and improve child health in endemic regions.
As the world battled with COVID-19, to the African region, this was the latest in a long list of infectious diseases crippling its health systems. A recent WHO report notes that out of all the 215 million malaria cases reported globally in 2019, 94% were from sub-Saharan Africa. Half of the infections in Africa were concentrated in five countries where malaria is endemic. What this implies is that Africa cannot yet join the rest of the world in celebrating the sustained reduction of malaria cases witnessed in the last two decades.
Malaria still, severely, impacts life and health in Africa and remains one of the continent’s biggest killers. It is estimated that four out of 10 pregnant women are exposed to the malaria parasite, leading to maternal deaths, underweight children, and potential lifelong disabilities. These may have contributed to the death of more than 250,000 children under the age of five in Africa in 2019. Households sink deeper into poverty as they deal with increased out-of-pocket expenditures in accessing care and treatment. Additionally, modelling studies have shown that COVID-19-related disruptions in access to effective antimalarial treatment are likely to reverse all progress made in reducing morbidity and malarial deaths in Africa.
A three-decade commitment
However, a recent WHO recommendation for the use of Mosquirix, a promising malaria vaccine, brings hope to the promotion of child health in malaria-endemic regions. This comes after three decades of commitment and investment, with vaccine trials carried out in seven sub-Saharan African countries. Amref Health Africa wishes to recognise and applaud the continued commitment of GSK; Gavi, the Vaccine Alliance; PATH; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the Bill and Melinda Gates Foundation, among other partners, for the successful conclusion of the trials. That said, the work has just begun to administer the vaccine, at scale, to those at greatest risk. It will require effective vaccination programmes for the successful integration of the malaria vaccine into other programmes such as Maternal and Child Health and routine immunisation.
It is estimated that approximately one in every four children in Africa does not receive all the recommended childhood vaccines, thus heightening the risk to vaccine-preventable diseases and exposing the cracks in the current routine immunisation programmes. Leveraging such a sub-optimal routine immunisation infrastructure in rolling out the malaria vaccine would, therefore, mean that we will only achieve similar limited coverage despite the intended benefit of the vaccine. Improving performance in the immunisation programme would, therefore, include investment in systems such as vaccine logistics and cold chain infrastructure.
In addition, strengthening the capacities of the health workforce is paramount given the role that health workers play in building confidence in new vaccines amongst community members and this case amongst mothers visiting health facilities for antenatal care and routine immunisation for their children.
Community Health Workers key to improving uptake
Surveys conducted in sub-Saharan Africa in the last two decades found that Community Health Workers (CHWs) were involved in an average of less than 2% of malaria programmes, making a strong case for further investment in community health systems to create awareness and build momentum for the vaccine ahead of time.
A strategic communication plan that addresses common barriers to vaccination uptake such as gender, beliefs, and socio-cultural factors facing caregivers would come in handy in improving uptake of this and other childhood vaccines.
As observed in the COVID-19 vaccine development journey, it will require sustained bilateral and multilateral funding and coordination through instruments such as GAVI and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) for accelerated production and distribution of vaccines where they are most needed. Amref Health Africa, with support from the Global Fund, has over the last ten years working with Civil Society Organisations (CSOs) in combating the constant threat of malaria in the sub-Saharan African region and believes in the advantage that such partnerships and collaborations present in creating safer and more equitable societies free from malaria.
The urgency of scaling up local production
COVID-19 has revealed how dependency on foreign production of medical commodities affects the ability to effectively respond to disease threats in the region. The recent experience in the production and supply of the COVID-19 vaccine to the region has pushed this conversation to the top of the agenda. The malaria vaccine provides an opportunity to use this momentum to accelerate local production in the African region. Africa currently imports 99% of all its vaccine requirements which create a favourable market for any investor interested in the domestic production of vaccines in the region.
Increased and sustained political commitment through platforms such as the Africa Leaders Malaria Alliance (ALMA), a coalition of African Union Heads of State and Governments who are committed to eliminating malaria by 2030, can accelerate the roll-out of the vaccine in the region. Africa CDC, which has played a major role in coordinating the COVID-19 response and promoting equity in access to the vaccine, can now extend this role to encompass the management of supply and demand of the malaria vaccine in sub-Saharan Africa.
As the world moves towards increased health security, a system-wide approach to building health system resilience will be required to enhance the regulatory environment and infrastructure required for effective deployment of routine immunisation programmes which will include the malaria vaccine. African governments must ensure that this is made possible through the timely establishment of the right policy frameworks that integrate malaria vaccination in routine immunisation programmes. The regulatory environment which includes local Drug Regulatory Authorities will need proper backing by law and policies to regulate and fast-track malaria vaccine approvals and use in countries.
No silver bullet
While immunisation remains the most impactful public health measure to avert disease and death, we must not forget the role that other anchor malaria control efforts such as vector control, through the use of insecticide-treated mosquito nets and indoor residual spraying, have contributed to the gradual reduction of malaria in the African region. These should continue to be employed, alongside vaccination, as part of a holistic approach. Unfortunately, the constant threat of parasite resistance to insecticides and antimalarial drugs remains. This makes it necessary for researchers to intensify studies on vector control, which not only causes malaria but also other Neglected Tropical Diseases (NTDs) that continue to cripple the region such as dengue fever, West Nile virus, and Chikungunya.
Amref Health Africa is committed to continuing its support to African governments in putting-up policy frameworks that promote health systems strengthening through a strong workforce, robust surveillance with full involvement of community health systems to support vector control, early detection of disease outbreaks, demand creation, and timely referrals for proper diagnostics and treatment. The malaria vaccine is a timely and necessary add-on that will accelerate the journey to UHC for all.